Azithromycin in Asthma Associated With Fewer Exacerbations

In an observational study reported at CHEST 2021, the American College of Chest Physicians annual meeting, Hanan Ajay, a fifth-year medical student at the University of Liverpool in England, said that of 34 patients on azithromycin, nearly all had reduced infection rates compared with historical averages.

In this exclusive MedPage Today video, Ajay is joined by lead author Aravind Ponnuswamy, MD, a consultant respiratory physician at Countess of Chester Hospital NHS Foundation Trust in England, to discuss the background and takeaways of the study.

Following is a transcript of their remarks:

Ajay: I’ve been given the opportunity to do this research paper, and basically the research paper revolves around the condition of asthma, which is very prevalent worldwide affecting 300 million people. In America, I believe it affects one in 13 people. And asthma is a very broad condition. So the severity ranges from person to person. But what we looked at is a real-world study of long-term use of azithromycin as a prophylactic in asthmatic patients.

What you need to consider is, asthma is treated in a stepwise way. So if we look at the BTS [British Thoracic Society] guidelines — which is a very prominent figurehead within the U.K., their recommendations is what I usually follow — they’ve actually recommended long-term macrolide use at a low dose to prevent asthma exacerbations. But this is in addition to all the other treatments that are already available, like inhaled corticosteroids.

So the treatment they recommended — the low-dose macrolides — this is if adherence to high-dose steroids is still not helping. And the patient is still requiring steroids because they’re having exacerbations in a year. So that’s when you think about using low-dose macrolide. And the one of choice is usually azithromycin because compared to other macrolides, it’s actually found higher in concentration in the respiratory secretion. So that’s probably the best one to use.

With regards to, “Does azithromycin thwart asthma exacerbation?” — it’s definitely not a miracle drug. So azithromycin should not replace steroids in acute asthma exacerbations, but definitely azithromycin does have a place in treatment. But the risk and benefits should be discussed between the patient and the clinician, so that holistic patient care is achieved.

So we’ve established azithromycin is not a replacement, but it has a lot of benefits. So azithromycin is both antibacterial and anti-inflammatory. And so it’s a great drug to use. With our study itself, we’ve actually reported that there was a 6.44 infection rate [per year] before, whereas after it’s 1.52 with azithromycin use, and this was statistically significant and it was actually really great to see. So considering all of this we’ve piled together the actual research and put it in a poster presentation, which I was able to present at CHEST.

Ponnuswamy: What was the key clinical implications of this study is that compared to previous randomized control trials, this particular study has confirmed the findings that in asthma management, azithromycin has got a well established role. What the British Thoracic Society guidelines did say was that we use 500 mg three times a week. What we have shown in our study was that even 250 mg three times a week was effective in reducing the number of exacerbations.

Moreover, this is a real-world study. A real-world study is increasingly becoming an important aspect of evidence-based medicine, because what the research does is it takes into consideration patients who originally joined the study. Whereas the real-world study is actually what the world study population is, showing the changes.

So one of the other findings we had was that the side-effect profile of gastrointestinal issues was much better in our study. The key method mechanisms by which azithromycin works is by its antibacterial, its anti-inflammatory, and its anti-reflux measures. So the future is that we hope this will be used in most of the guidelines and become an established aspect of asthma management.